In 1854 Dr John Snow plotted cholera outbreaks in Soho, London, and related them to a contaminated water supply, dispelling the myth it was spread by miasma in the air. In 1890s New York Jacob Riis used photographs to graphically illustrate the squalor among the tenements, describing “evils more destructive than wars” that impacted catastrophically on the health and well-being of those that were crammed into them.
These two examples stimulated significant social change by taking a broader view of the problem to help identify the underlying causes. We know that around two-thirds of our health is conditional on wider social and environmental determinants. It’s widely accepted that health starts in our homes, schools, workplaces, neighbourhoods, and communities, and yet the definition of our ‘health care system’ remains narrow and deeply protective of existing processes, systems and vested interests. And yet somewhere along the way the UK health, social care, environmental and public health systems have grown into silos, driven in part by an application of Taylorism to the organisation and management of public services (the notion of top down, rigidly pre-determined, ‘scientific’ management of behaviour and compounded by a prioritisation of fixing ill-health as it arises rather than preventing it arising in the first place.
This deficit model means that treating people when they are ill still takes priority over prevention and public health which are never truly brought within the health system’s incentive structure. Policy-makers have long recognised the need to shift resources from downstream fixes to upstream interventions that address the wider determinants that impact on health, but this requires fundamental change that is not only technically difficult but also, in my view, largely unwanted by the government despite its rhetoric. And even if these challenges are overcome the required change still needs to be driven-though both politically and managerially, co-ordinated across organisations, professions, sectors and generations.
If this challenge is to be met it will need organisation- and system-wide structures to be rethought and reconfigured with people at their heart. Recent austerity measures and the acknowledgement of a population time-bomb haven’t yet led to truly transformational system redesign. So under what scenarios might this happen? How can we, for example, break down the barriers between acute, primary and community care whilst engaging people and communities as part of the solution? As one Clinical Commissioning Group manager recently said to me, “You simply can’t put people in the same team and assume that’s the same as integrated working”.
What does it take to change a complex system of public and voluntary services? Existing systems and bureaucratic structures act as barriers to the kind of change necessary to place people at the heart of their own health. If system redesign is a longer-term ambition, what can we do in the short-term to support people to make small scale changes in their working practice and culture that will enable integration and improvement? At the heart of this work are what academics call ‘boundary-spanners’, those natural influencers and collaborators who drive innovation and change across systems for the benefit of local people, being more interested in what works than who takes the credit. These people are often the drivers of change, leveraging the strengths of teams and employees regardless of their position, status or organisation. It is important to recognise and legitimise the value they add, for the work to shift systems is not done by people or teams in isolation,
We now take for granted the historic improvements made in sanitation and housing and their positive impact on our individual and population health that Snow and Riis and others precipitated. Yet it is estimated that the National Health Service in England spends £1.4bn a year on treating people who suffer illness or physical harm linked to poor housing quality, to take but one example. The timing seems right for a further series of revolutionary advances in the way we approach health improvement in its widest sense.